Stress, Burnout, Humor, and Happiness David Mays, MD, PhD dvmays@wisc

1. Stress, Burnout, Humor, and HappinessDavid Mays, MD, PhDdvmays@wisc.edu

2. The Chronobiology of Getting Sick • 12 - Gout • 1 AM - Gallbladder • 2 AM - GERD, peptic ulcer • 3 AM - Congestive heart failure, pulmonary edema • 4 AM - Cluster and migraine headaches • 5 AM - Asthma attacks

3. 6 AM - Death, all causes • 7 AM - Allergic rhinitis, colds, flu, rheumatoid arthritis, depression • 8 AM to Noon - Angina, MI, sudden cardiac death, TIA, stroke • 1 PM - Stomach ulcer perforation • 4 PM - Tension headache

4. 5 PM - Intestinal ulcer perforation, osteoarthritis • 7 PM - Cholesterol rises • 8 PM - Backache • 9 PM - Restless legs syndrome • 10 PM - Menopausal hot flashes

5. Stress • 50-75% of routine medical practice is devoted to complaints related to stress. • Problems at work are more strongly associated with health complaints than any other life stressor. 29% of workers report that they feel “quite a bit or extremely stressed at work.” (Yale Univ. Survey, 1997) • Healthcare expenditures are 50% greater for workers who report high levels of stress (J of Occ Env Med, 1998)

6. Stress • Obviously, there is an adaptive component to the fight or flight phenomenon. There may also be an adaptive feature to being afraid of loneliness, or shutting down when we are afraid/depressed, which can save energy or elicit concern from others. • Just as obviously, there is a physical cost from being stressed. • Not so obvious is defining exactly what stress is.

7. What is a stressful experience? • The experience must be unpleasant. (Would you avoid this experience if you could?) • The experience must lead to a heightened degree of arousal. • The experience must be out of the subject’s control. This determines the intensity of the response. And it is the intensity of the response that determines the degree of stress-induced problems on the organism.

8. Stress Response: LC/NE Pathway • LC/NE: The locus coeruleus (LC) secretes norepinephrine (NE - related to adrenaline) in the cortex, thalamus, limbic system, hypothalamus, spinal cord. NE acts as a neuromodulator. It also activates the autonomic nervous system for fight or flight. Heart rate, respiration, and blood pressure increase.

9. Stress Response: HPA Axis • Hypothalamic: When stress is perceived, corticotropin-releasing hormone (CRH) and vasopressin are secreted by neurons in the hypothalamus. CRH causes the pituitary to secrete ACTH. ACTH stimulates the adrenal gland to release cortisol which increases glucose levels and suppresses the inflammatory/immune response. This is the hypothalamus-pituitary adrenal axis (HPA.)

10. Cortisol • The levels of glucocorticoids in the blood typically follow a daily rhythm - high early in the morning, low later in the day. They increase glucose in the blood, control its metabolism, and regulate the sleep wake cycle. • High levels of cortisol have many deleterious effects on the body (Cushing’s disease).

11. Stress: Memory Effects • The amygdala is a central brain structure that processes fearful stimuli. It is directly connected to the hippocampus. • The hippocampus is primary structure involved in memory formation. • Short term stress can enhance memory. But chronic stress can impair attentional states and learning later on. Ultimately, even amnesia can be result. • High levels of glucocorticoids lead to impaired memory and neuronal cell death.

12. Chronic Stress • Chronic stress results in hypertrophy of the adrenal gland and persistent elevations of cortisol. The LC also fires faster at lower levels of stimulation. • These changes result in depression of reproductive functioning, reductions in growth hormone, vagus nerve blockade (GI shutdown), insulin resistance, depression, panic, and anxiety. • Uncontrollable stress produces reductions in LC-NE levels - depression, learned helplessness.

13. Common Physical Symptoms of Stress • Headache • Back, shoulder, neck pain • Sleep problems • Difficulty concentrating • GI problems • Palpitations • Skin problems • Tics • Low energy

14. Common Emotional Symptoms of Stress • Job dissatisfaction • Burnout • Irritability • Anxiety • Depression • Isolation, withdrawal

15. The Dimensions of Burnout • Exhaustion: individual stress component - feeling overextended, depleted of one’s emotional and physical resources • Cynicism: interpersonal component -negative or callous, excessively detached response to job • Reduced efficacy/accomplishment: feelings of incompetence and lack of achievement and productivity

16. Burnout Effects • Burnout is associated with various forms of job withdrawal: absenteeism, turnover • For people who stay on at work, burnout leads to lower productivity and effectiveness, poor job satisfaction, reduced commitment. • Burnout has a negative impact on coworkers, creating more interpersonal conflict and disruption. It is contagious.

17. Leadership • The mood of a leader is more powerful than the mood of members of the group. In several studies that have measured leaders and workers moods before and after a task, the leaders mood has proven to be very contagious. • Interestingly, “negative” contagion seems to be stronger than “positive” contagion.

18. Symptoms of Burnout • Physical Symptoms: fatigue, cognitive impairment, sleep disruption, GI problems, headache, inflammatory changes • Emotional Symptoms: alienation, cynicism, powerlessness • Behavioral Symptoms: impatience, negativism, frustration, irritability

19. Job/Situational Causes • Overload: exhaustion • Role Conflict: competing demands • Role Ambiguity: lack of training • Severity of Client’s Problems • Lack of Support from Supervisors (more so than coworkers)

20. Job/Situational Causes • Lack of Feedback • Lack of Control • Lack of Autonomy • Lack of Reciprocal Loyalty • Lack of Perceived Fairness

21. Job/Situational Causes • The psychological contract:When we first begin working for an organization, we have certain expectations about what that employment will entail - the job we will be doing, workload, resources, career advancement, job security, etc. Larger social and economic forces can bring about significant changes in these things.

22. Personal Causes • These causative factors are not as strong as situational factors • Younger, unmarried • Gender neutral (although males tend to rate higher in cynicism)

23. The Mismatch Paradigm of Burnout • Burnout arises from mismatches between the person and the job in six domains. The greater the mismatch, the greater the chance of burnout. The better the match, the greater the likelihood of job engagement. • Mismatches arise when the initial psychological contract was not clear, or the job changes. • The six areas are: workload, control, reward, community, fairness, and values.

24. 1) Workload • Energy can be exhausted to the point that the person can no longer recover. • Mismatch can also result from the wrong kind of work in terms of skills or inclination. • Work is especially draining when it requires people to display emotions inconsistent with their feelings.

25. 2) Control • Mismatches occur most often when workers feel they do not have control over resources needed to do their job most effectively. • Workers may also feel overwhelmed by their responsibility and feel that their responsibility exceeds their authority.

26. 3) Reward • Financial rewards • Social rewards are even more important to most people. Feeling lack of appreciation and having one’s hard work ignored devalues the work and the worker. • Lack of intrinsic reward (pride in work) is also critical for burnout.

27. 4) Community • People can lose a sense of positive connection with others at work. People thrive when they share praise, comfort, happiness, and humor with those they like and respect. They have a shared sense of values. • Jobs may isolate workers from one another, but what is most destructive is chronic, unresolved conflict.

28. 5) Fairness • Fairness communicates respect and confirms people’s self-worth. • Inequity of pay, workload, when there is cheating or when promotions and evaluations are mishandled, or when grievances are not handled appropriately all increase cynicism and emotional exhaustion.

29. 6) Values • Employees may feel that their job requires them to act unethically (lie). • They may feel that their personal values are at odds with their workplace, or that their workplace has contradictory goals (maintain a high case load, be culturally sensitive.)

30. Job Mismatch • Individuals may place different importance on these six factors. If you really support the values of the organization, you may be able to tolerate problems with reward, for example. • Investigating job mismatch is a very fruitful way to help supervisors and employees concretely discuss burnout and encourage engagement.

31. Individual Interventions • People can learn new coping skills, but it has not been shown that they can apply it at work • At best, there may be a reduction in exhaustion, but generally there is no change in cynicism or self-efficacy. • The most effective change requires integration of workplace and individual needs.

32. Goals of Complaining • venting • prevents internal rumination • communicates • saves face • diffuse negative emotional experiences • helps develop insight • expresses solidarity • socialization

33. Negative Effects of Complaining • people find it annoying • it affects how people perceive you • it makes others more dissatisfied

34. Leadership • The mood of a leader is more powerful than the mood of members of the group. In several studies that have measured leaders and workers moods before and after a task, the leaders mood has proven to be very contagious. • Interestingly, “negative” contagion seems to be stronger than “positive” contagion.

35. People high in negative affect are no less healthy and do not have a higher mortality than positive people. They just complain a lot.

36. Defensive Pessimism, Strategic Optimism • Defensive pessimism - a strategy that anxious individuals may use by setting low expectations and rehearsing negative outcomes. • Strategic optimism - a strategy of setting optimistic expectations for outcome and avoiding extensive reflection.

37. Who Does Better? • Both groups do equally well on tasks and both show performance decrements when not allowed to use their preferred strategies. • Optimists tend to feel better and be more satisfied. • You can cheer the pessimists up, but a positive mood impairs their performance and does not make them feel more satisfied.

38. The Power of Negative Thinking • In the elderly and the sick, defensive pessimism may improve outcome and adaptation. • Unrealistic optimism may blind people to feedback and prevent normal precautionary measures. • There is little empirical evidence that people can change their coping styles, and there is ample evidence that their performance deteriorates when they try.

39. Life is not being dealt a good hand. It is playing a poor hand well. Anonymous

40. Laughter • Nobody understands humor. • The biggest laugh getters at social occasions are not jokes (99% of people can’t remember a joke) but remarks like “see you later” or “must be nice.” The speaker laughs more than the listeners. • Laughter is not necessarily linked to humor. We seldom laugh at funny things when we are alone, for example, but we laugh quite quickly when meeting an old friend.

41. Laughter • Robert Provine, Univ Maryland, traveled streets of Baltimore with a video camera, asking people to laugh. They couldn’t facing the camera, but when they turned to a person next to them, they could. • Often we’re not even aware we’re laughing. It is very much out of our conscious control. It is located in the brainstem (stroke victims). • Chimps laugh and tickle each other throughout life.

42. The Physical Effects of Laughter The Physical Act of Laughing: • Increases respiration and oxygen exchange • Activates muscles - and then relaxes intercostals, abdominals, diaphragm, muscles of neck and shoulders. A hearty belly laugh effects almost all muscle groups. • Stimulates cardiovascular system • Stimulates sympathetic nervous system • Raises blood pressure during laughter, lowers it after • Body temperature increases • Increases release of endorphins and enkephalins • Increases salivary immunoglobulin A

43. Function of Laughter • All of these things make sense if we regard laughter as a facilitator of human bonding, which is a necessary component of health. • “The shortest distance between two people is a laugh.” Victor Borge

44. Development of Humor • Babies smile around 6 weeks, and later chuckle when their mother plays with them. At 10 weeks, a baby smiles at surprises and relief. At 16 weeks, the baby is smiling about 1x per hour. By 10 months, visual and social stimuli are beginning to elicit smiles, like when mom crawls on the floor like a baby. Around 11-12 months, the baby begins to take the initiative in fun: peek-a-boo. Around 4 years old, we see the first signs of kids laughing at themselves.

45. Humor Test • The neighbor approached Mr. Smith at noon on Sunday and inquired, “Say, Smith, are you using your lawnmower this afternoon?” • “Yes, I am,” Smith replied warily. • The neighbor answered: • A. “Oops,” as the rake he walked on hit him in the face. • B. “Oh, well. Can I borrow it when you’re done?’ • C. “You won’t be wanting your golf clubs. I’ll borrow them.”

46. Richard Wiseman • Two thousand jokes, generally 4 themes: • Trying to look clever and messing up • Husband and wife conflict • Doctors being insensitive to imminent death • God making a mistake • The funniest animal is a duck • The funniest joke…

47. Why are things funny? • More than 100 theories • Superiority theory (aggression): Plato, Aristotle • Incongruity theory: Pascal 17th Century (surprise - coherence, tension release) • Release theory: Freud, Jokes and Their Relation to the Unconscious • “A quota of psychical energy which has earlier been used for cathexis of psychical paths and become unusable so that it can find free discharge.”

48. Criteria for Humor • 3 criteria for determining appropriateness of humor: 1) Timing 2) Receptivity 3) Content • Genuineness of the interpersonal relationship. The relationship must be non-exploitive, respectful, tolerant.

49. Criteria for Humor Impediments to humor: • confusion • depression • paranoia • offensiveness

50. Humor and Psychotherapy • Inhibitions are released, aids clients feeling relaxed, letting go of defenses • Aids diagnosis • May facilitate moments of insight • Helps build perspective